A Prospective, Randomised Trial of Chlorambucil, Mitoxantrone and Dexamethasone (CMD) Versus Fludarabine, Mitoxantrone and Dexamethasone (FMD) for Advanced Follicular Lymphoma (Real Grades I-III, Stages III/IV).

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Fludarabine, alone and in combination, has activity in de novo and relapsed/refractory follicle centre cell lymphoma (FCCL), as do many other combinations of chemotherapy, including chlorambucil, mitoxantrone and steroids. In this multicentre study, between May 2000 and April 2006, 400 adults with FCCL (REAL grades I-III) were randomised to receive either CMD (chlorambucil 10mgs po, od, days 1–10, mitoxantrone 12mgs/m2 IV, day 1 and dexamethasone 20mgs po, od, days 1–5) or FMD (fludarabine 25mgs/m2, IV days 1–3, with M and D as for CMD) on physicians' decision to treat advanced stage (III or IV) disease (B symptoms, bone marrow failure, bulk or progression and compression syndromes). Rituximab (R) was not available for this trial. Randomisation was prospectively stratified by IPI score. Patients received four courses before assessment of response, then had no further trial therapy with progression or inadequate response or had a maximum total of eight courses if responding. The primary end points were progression-free survival (PFS) and overall survival (OS) and the secondary end points were complete (C) and partial (P) remission rates (RR). This preliminary report is at median follow-up of 31 months (range 0–71). Clinical features and pathological diagnoses (reviewed centrally) were equivalent across both arms. The median age in years (range; number >60 y) for CMD was 56 (32–72; 68) and for FMD 55 (29–75; 68) and 70% in both arms had stage IV FCCL. For CMD versus FMD, the CRR and PRR after course 4 were 18% v 21% and 72% v 68% and after course 8 or at the end of treatment were 44% v 45% and 47% v 47%. The hazard ratios were in favour of CMD, for OS at 1.65 (95%CI 0.97–2.8, p=0.063) and for PFS at 1.61 (95%CI 1.2–2.17; p=0.0018). The numbers of deaths due to lymphoma were equivalent (19 v 21) but there were fewer deaths in the first year (most due to lymphoma in both arms) with CMD (7 v 15; ns). The difference between those who received between 6 and 8 courses in either arm was not significant (152[80%] v 135[71%]). With CMD there were higher rates of grade 3/4 neutropenia (8 v 1) and infections (29 v 20) but these differences were not statistically significant; other toxicities were low grade and equivalent for both arms. Days between cycles (median 28 days in both arms) and dose adherence (96% and 97%) were equivalent; both regimens were well tolerated and relatively easy to deliver. The equivalent dose intensity, toxicities and RRs of the two arms indicate that the statistically significant superior PFS for CMD was not due to undertreatment in the FMD arm. The outcomes for CMD are at least as good as those reported for other combinations of chemotherapy without R and R-CVP.